ATI - Comprehensive Practice 2019 A, RN Comprehensive Online Practice 2019 B with NGN Questions and Answers

ATI - Comprehensive Practice 2019 A, RN Comprehensive Online Practice 2019 B with NGN Questions and Answers a nurse is planning care for a client who is receiving heparin to treat a deep vein thrombosis of the left lower leg. which of the following interventions should the nurse include in the plan of care? ANSWER elevate the affected leg ambulation should be encouraged Ensure that the client understands the medication regimen. ANSWER Ensure that the client understands the medication regimen. The priority action the nurse should take when using the safety vs. risk reduction approach to client care is to ensure the client understands the medication regimen. The greatest risk to the client is the potential to develop hypoglycemia or hyperglycemia, which can be life-threatening if treated incorrectly. A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up. Speech Neuro status Weight Restlessness Auditory hallucinations ANSWER Speech Restlessness Auditory hallucinations When recognizing cues, the nurse should identify that the findings of restlessness, auditory hallucinations, and pressured speech require immediate follow-up. These findings are indications of psychosis. The nurse should notify the provider for additional evaluation and treatment.